HomeMy WebLinkAboutApp-Permit-ComplianceNo (;�
O COMMONWEALTH OF MASSACHUSETTS
Board of llealth,llJ' _ , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION P_
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components
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Location { o
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Owner's Name -DAvtb 4.! Z 0
Map/Parcel#
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Address '� • g
Lot#
j 117 2
Telephone#
Installer's Name
F�1�� �l�✓ 1�15s
Designer's Name _iV -li�!�i•x75�Ga
Address
�(1GC�Gfc�!}C.. r-
Address a2S4 ,
Telephone#
Telephone# Soo - d-73,, d3-77
Type of Building kc -s [ r.> &-om 4-k- Lot Size 4- sq. ft;
Dwelling - No. of Bedrooms 13 Garbage grinder {
Other - Type of Building No. of persons Showers O,'Cafeteria
Other Fixtures
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Design Flow (min, required) l✓ gpd Calculated design flow Design flow provided gpd
Plan: Date a -15 - cxO12 Number of sheets I Revision Date
Title
Description of $'oii(s) _
Soil Evaluator Form No
Name of.Soil Evaluator M 4 1.)lmd kAJ Date of Evaluation LL 9i " AO l
1
DESCRIPTION OF REPAIRS OR ALTERATIONS TPSTA-c - �Jta,) 1 -1 -to 1 !; ao Ge*u of -) cS 8kt<- I-AAJL,
The undersigned agrees to install the above described Individual: Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in oper on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
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Inspections
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CO MONWEALT14 OMASSACHUSETTS ��i�'
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Board of Health,
CERTIFICATE Of COMPLIANCE
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Description of Works ❑ Individual Component(s) ❑ Complete System - 3
The undersigned hereby certify that the Sewage Disposal System Constructed O, Repaired ( ), Upgrade Abandoned( )'
by CAP&, .fit l7 G P C ML b CAPst.l
at lo OVA -C. n It 1 O E
has been installed ir�accorda ce with the provisions of 0 CMR 1.5.00 (Title 5) and the pp ved design plans/as-built plans relating to
application No. � ~ , dated % /.' Approved Design Flow "f (gpd).
Installer D&W i b G t'&JIISUAVAM >
Designer: -TNCo Inspector: Date:
The issuance of this permit shall not be construed as a,guarano that the system will function as designed.
FEE .''ko
No. -T
4. 4 COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission isshhereby granted to; Construct( ) Repair'( ) UpgradeT, Abandon( ) an individualsewage disposal system
at U DY b i u � as described in. the application for
Disposal System Construction ;Permit No. /9" dated
Provided: Construction shall be completed within three1Ae date of this permit. Evil local conditions' zaust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslon, MA Date ``J �� ` y Board of Health ( ! ! ✓ �'